CME LECTURE 2016

General data

G.M.G
68 year old female
Filipino
Roman Catholic
From Guadalupe, Cebu City
Chief complaints: Cough and Dyspnea
 Past medical history

Hypertensive for 20 years

UBP: 120/80mmHg HBP:140/90mmHG
tab 16mg Candesartan(Candez)
tab 25mg Carvedilol(Carvid
Personal and social history

Known cigarette smoker for 25 years

consuming 25pack/year
Occasional alcoholic beverage drinker
No history of illicit drug use
No known food and drug allergies
 Family history

(+) Hypertension,
(+)Diabetes Mellitus,
(+)Bronchial Asthma
 History of present illness

Problem #1: Cough and Dyspnea

One week PTA

Onset of cough, (+) greenish sputum
Undocumented fever and chills
Took Carbocysteine 30mg/tab 1 tab with no
relief
Condition tolerated, no consult done
(-) dyspnea, (-) hemoptysis, (-) body malaise,
(-) anorexia, (-) night sweats, (-) sore throat
 History of present illness

Problem #1: Cough and Dyspnea

5 days PTA
On and off fever (temperature not taken)
Persistence of productive cough with
greenish sputum
No improvement nor worsening of
symptoms
Condition tolerated
No consult done
History of present illness

Problem #1: Cough and Dyspnea

Two days PTA
Productive cough and fever persisted
Now associated with dyspnea, body
malaise, anorexia and insomnia
(-) hemoptysis, (-) chest pain, (-) sore throat
(-)orthopnea, (-)exertional dyspnea
Persistence of symptoms prompted
admission
 PHYSICAL EXAM on admission

Conscious, coherent, cooperative

In respiratory distress, febrile
BP = 120/80 mmHg
T = 38 C
HR = 120 bpm
RR = 32 cpm
O2 saturation = 98%
 PHYSICAL EXAM

SKIN:
good mobility and turgor,
HEENT:
pink palpebral conjunctiva, anicteric
sclerae, nasal septum at midline, no alar
flaring, sinuses non-tender, non-hyperemic
tonsillopharyngeal wall
 PHYSICAL EXAM

NECK :
supple, trachea at midline, no
lymphadenopathies,
CHEST & LUNGS:
equal chest expansion, increased tactile
fremitus and (+)rales heard over right lower
lung field) (-)intercostal retractions
 CVS:
PMI visible at 6th LICS AAL, 2.5cm in
diameter, bounding, (+) heaves, Heart rate:
114bmp, (+) systolic and diastolic murmur,
Grade IV, no extra heart sounds
ABDOMEN:
Flabby, NABS, soft, nontender, no
organomegaly
 PHYSICAL EXAM

GUT:
(-) KPS, bilaterally
EXTREMITIES:
CRT < 2 s, strong peripheral pulses, no
edema
NEUROLOGIC EXAM:
All within normal limits
Diagnostic,Empiric Management and
Prevention of Community-Acquired
Pneumonia In Immunocompetent Adults

2016 UPDATE
Changes Emerged in 2016
update

Multiple international societies had published

and revised their guidelines of the
management of patients with CAP
New organism had emerged and
development of resistance had increased
over time among respiratory pathogens
Changes emerged in 2016
Update

The influx and efflux of antimicrobial agents

used in the treatment had likewise posed a
threat to the rapid rise of antimicrobial
resistance. The use, misuse, abuse, and
overuse had also shaken the market of
antimicrobial agents.
Should antibiotics be initiated for the
empiric treatment of community-acquired
pneumonia(CAP)?

Patient should receive initial therapy as

soon as possible after the diagnosis is
established.
Antibiotics, the mainstay for the
treatment of pneumonia.
The 2004 PCPG for CAP recommended a
maximum four-hour window from
diagnosis to antimicrobial initiation.
 Showed a reduced in-hospital mortality when
antimicrobial therapy was initiated w/I the
first four hours of admission and diagnosis of
CAP.
 LOW RISK CAP

Stable Vital Signs No altered mental state of acute

RR <30/min onset
PR <125/min N0 suspected aspiration
SBP >90 mmHg No or stable co-morbid conditions
DBP >60 mmHg Chest X ray
Temp >36C or <40C - Localized infiltrates
- No evidence of pleural effusion
 MODERATE RISK CAP
Unstable Vital Signs: Altered mental state of acute onset
RR >30/min Suspected Aspiration
PR >125/min Unstable/Decompensated comorbid
SBP <90 mmHg condition
DBP <60 mmHg - uncontrolled diabetes mellitus
Temp <36C or >40C - Active malignancies
- Neurologic disease in evolution
- Congestive heart failure (CHF)
class II-IV
- Unstable coronary artery disease
- Renal failure on dialysis
- Uncompensated COPD
- Decompensated liver disease
 HIGH RISK CAP

Any of the clinical feature of Moderate Risk CAP plus any of the following:

Severe Sepsis
Septic Shock
Need for Mechanical Ventilation
 What INITIAL antibiotics are recommended
for the EMPERIC treatment of community-
acquired pneumonia?
 LOW RISK Emperic
Treatment

For low risk w/o comorbid illness,

AMOXICILLIN still remains the standard drug
of choice, use of extended macrolides may
also be considered
For low risk with comorbid illness, Beta
lactam and Beta Lactam inhibitor
combination(BLIC) or second generation
cephalosporin w/ or without extended
macrolides are recommended.
LOW RISK Emperic Treatment

For patients who have completed first-line

treatment (BLIC and 2nd gen cephalosporin)
with no response, an extensive work up
should be done
Work up may include sputum gram stain and
culture
 Moderate Risk CAP Emperic
Treatment

Combination of an IV non-antipseudomonal
B-Lactam(BLIC, cephalosporin) w/ either an
extended macrolides or a respiratory
fluoroquinolone as initial treatment
High Risk CAP Emperic Treatment
w/o Risk of P. aeruginosa

Combination of an IV non-antipseudomonal
B-lactam(BLIC, cephalosporin or
carbapenem) w/ either an IV extended
macrolide or an IV respiratory
fluoroquinolone
High Risk CAP Emperic Treatment
w/ Risk of P. aeruginosa

Combination of an IV antipneumococcal,
antipseudomonal B-Lactam(BLIC,
cephalosporin or carbapenem)
w/ an extended macrolide and aminoglycoside
or

IV ciprofloxacin ir high dose IV levofloxacin

 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION

RISK POTENTIAL EMPIRIC

STRATIFICATIO PATHOGEN THERAPY
N
LOW RISK CAP Streptococcus WITHOUT CO MORBID
pneumoniae ILLNESS
Haemophilus influenzae Amoxicillin 1gm TID
Chlamydophila OR
pneumoniae Extended macrolides.
Mycoplasma pneumoniae Azithromycin 500 mg OD
Moraxella Catarrhalis OR Clarithromycin 500
Enteric Gram-negative mg BID
bacilli
(among those with co-
morbid illness)
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION

RISK POTENTIAL EMPIRIC

STRATIFICATIO PATHOGEN THERAPY
N
LOW RISK CAP Streptococcus WITH STABLE CO-
pneumoniae MORBID ILLNESS
Haemophilus influenzae Beta-lactam/Beta-
Chlamydophila lactamase inhibitor
pneumoniae combination (BLIC) OR 2nd
Mycoplasma pneumoniae GEN ORAL Cephalosprorin
Moraxella Catarrhalis +/- extended macrolides
Enteric Gram-negative Co-Amoxiclav 1gm BID or
bacilli Sultamicillin 750mg BID
(among those with co- or
morbid illness) Cefuroxime Axetil 500mg
BID
+/-
Azithromycin 500 mg OD
or
Clarithromycin 500 mg
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION

RISK POTENTIAL EMPIRIC

STRATIFICATIO PATHOGEN THERAPY
N
MODERATE RISK Streptococcus IV non-antipseudomonal B-
CAP pneumoniae lactam (BLIC,
Haemophilus influenzae cephalosporin)
Chlamydophila + extended macrolides or
pneumoniae respiratory
Mycoplasma fluoroquinolones (PO)
pneumoniae Ampicillin-Sulbactam 1.5
Moraxella Catarrhalis gm q6h IV or
Enteric Gram-negative Cefuroxime 1.5 g q8h IV or
bacilli Ceftriaxone 2g OD
Legionella pneumophila +
Anaerobes (among those Azithromycin 500mg OD
with risk of aspiration) PO or
Clarithromycin 500mg BID
PO or
Levofloxacin 500mg OD PO
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION
RISK POTENTIAL EMPIRIC
STRATIFICATIO PATHOGEN THERAPY
N
MODERATE RISK Streptococcus If aspiration pneumonia is
CAP pneumoniae suspected and, a regimen
Haemophilus influenzae containing ampicillin-
Chlamydophila sulbactam and/or
pneumoniae moxifloxacin is used, there
Mycoplasma is no need to add another
pneumoniae antibiotic for additional
Moraxella Catarrhalis anaerobic coverage. If
Enteric Gram-negative another combination is
bacilli used may add clindamycin
Legionella pneumophila to the regimen to cover
Anaerobes (among those microaerophilic
with risk of aspiration) streptococci

Clindamycin 600mg q8h IV

or
Ampicillin-Sulbactam 3g
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION

RISK POTENTIAL EMPIRIC

STRATIFICATIO PATHOGEN THERAPY
N
HIGH RISK CAP Streptococcus NO RISK FOR P.
pneumoniae aeruginosa
Haemophilus influenzae IV non-antipseudomonal
Chlamydophila Beta-lactam + IV extended
pneumoniae macrolides or IV respiratory
Mycoplasma flouroquinolones
pneumoniae
Moraxella Catarrhalis Ceftriaxone 2 gm OD or
Enteric Gram-negative Ertapenem 1gm OD
bacilli +
Legionella pneumophila Azithromycin dihydrate
Anaerobes (among those 500mg OD IV or
with risk of aspiration) Levofloxacin 500 mg OD IV
Staphylococcus aureus or
Pseudomonas Moxifloxacin 400mg OD IV
aeruginosa
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION
RISK POTENTIAL EMPIRIC
STRATIFICATIO PATHOGEN THERAPY
N
HIGH RISK CAP Streptococcus RISK FOR P. aeruginosa
pneumoniae IV antipneumococcal
Haemophilus influenzae antipseudomonal B-lactam
Chlamydophila (BLIC, cephalosporin or
pneumoniae carbapenem) + IV
Mycoplasma extended macrolides +
pneumoniae aminoglycoside
Moraxella Catarrhalis
Enteric Gram-negative Piperacillin-tazobactam
bacilli 4.5gm q6h or
Legionella pneumophila Cefepime 2gm q8-12h or
Anaerobes (among Meropenem 1g q8h8
those with risk of +
aspiration) Azithromycin dihydrate
Staphylococcus aureus 500mg OD IV
Pseudomonas +
aeruginosa Gentamicin 3mg/kg OD or
Amikacin 15mg/kg OD
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION
RISK POTENTIAL EMPIRIC
STRATIFICATIO PATHOGEN THERAPY
N
HIGH RISK CAP Streptococcus RISK FOR P. aeruginosa
pneumoniae OR
Haemophilus influenzae IV antipneumococcal
Chlamydophila antipseudomonal B-lactam
pneumoniae (BLIC, cephalosporin or
Mycoplasma carbapenem) + IV
pneumoniae cipfroxacin/high dose
Moraxella Catarrhalis levofloxacin
Enteric Gram-negative
bacilli Piperacillin-tazobactam
Legionella pneumophila 4.5gm q6h or
Anaerobes (among those Cefepime 2gm q8-12h or
with risk of aspiration) Meropenem 1g q8h8
Staphylococcus aureus +
Pseudomonas Levofloxacin 750mg OD IV
aeruginosa or
Ciprofloxacin 400mg q8-
 EMPERIC ANTIMICROBIAL THERAPY WITH USUAL
RECOMMENDED DOSAGE IN 50-60KG ADULTS WITH NORMAL
LIVER AND RENAL FUNCTION
RISK POTENTIAL EMPIRIC
STRATIFICATIO PATHOGEN THERAPY
N
HIGH RISK CAP Streptococcus IF MRSA pneumonia is
pneumoniae suspected, add
Haemophilus influenzae
Chlamydophila Vancomycin 15mg/kg q8-
pneumoniae 12h
Mycoplasma OR
pneumoniae Linezolid 600mg q12h IV
Moraxella Catarrhalis OR
Enteric Gram-negative Clindamycin 600mg q8h IV
bacilli
Legionella pneumophila
Anaerobes (among those
with risk of aspiration)
Staphylococcus aureus
Pseudomonas
aeruginosa
 How can response to initial
therapy be assessed?

Temperature, respiratory rate, heart rate,

blood pressure, oxygen saturation, inspired
oxygen concentration should be monitored
to assess response to therapy.
Response to therapy is expected within 24-
72hours of initiating treatment. Failure of
response after 72hours of treatment is an
indication to repeat Chest radiograph.
 Follow-up of cultures blood and sputum are
not indicated in patients who respond to
treatment.
 What should de-escalation of
emperic antibiotic therapy be done?

De-escalation of initial emperic broad-

spectrum antibiotic or combination
parentheral therapy to a single narrow
spectrum parenteral or oral agent based on
available laboratory data is recommended
once the patient is clinically improving is
hemodynamically stable and has a
functioning GI tract.
 INDICATION FOR STEAMLINING OF
ANTIBIOTIC THERAPY
1. Resolution of fever for > 24 hours

2. Less cough and resolution of respiratory distress (normalization of

respiratory rate)
3. Improving white blood cell count, no bacteremia.

4. Etiologic agent is not a high-risk (virulent/resistant) pathogen e.g

Legionella, S. aureus, or Gram-negative enteric bacilli

5. No unstable comorbid condition or life- threatening complication such

as myocardial infarction, congestive heart failure, complete heart block,
new atrial fibrillation, supraventricular tachycardia, etc.

6. No sign of organ dysfunction such as hypotension, acute mental

changes, BUN to creatinine ration of >10:1, hypoxemia, and metabolic
acidosis
7. Patient is clinically hydrated, taking oral fluids and is able to take oral
medications.
Which oral antibiotics are recommended
for de-escalation or switch therapy from
parenteral antibiotics?

Choice of antibiotics following initial

parenteral therapy
Available culture result
Antimicrobial spectrum
Efficacy
Safety and cost
 When switching to oral antibiotics, either the
same agent as the parenteral antibiotics or
an antibiotic from the same drug class
should be used.
 ANTIBIOTIC DOSAGE OF ORAL
AGENTS FOR STEAMLINING OR
SWITCH THERAPY
ANTIBIOTIC DOSAGE
Amoxicillin-clavulanic 625 mg TID or 1 gm
acid BID
Azithromycin 500 mg OD
Cefixime 200 mg BID
Cefuroxime axetil 500 mg BID
Cefpodoxime proxetil 200 mgw BID
Levofloxacin 500-750 mg OD
Moxifloxacin 400 mg OD
Sultamicillin 750 mg BID
 How long is the duration of
treatment of CAP?

Low Risk uncomplicated bacterial pneumonia

5-7 days
Moderate Risk Bacterial pneumonia
7-10 days
Moderate Risk and High Risk CAP or those
with suspected or confirmed Gram Negative
28 days if associated with bacteremia
 M. pneumoniae and C. pneumoniae
10-14 days
L. pneumoniae
14-21 days
 A 5-day course of Oral or IV therapy for low-
risk CAP
10-day course of IV for Legionella pneumonia
is possible with new agents such as azalides
Patient should be afebrile for 48 to 72 hours
with no signs of clinical instability before
discontinuation of treatment.
 DURATION OF ANTIBIOTIC USE
BASED ON ETIOLOGY
ETIOLOGIC AGENT DURATION OF THERAPY
(DAYS)
Most bacterial pneumonias 5-7 days
except enteric Gram-negative
pathogens S. aureus (MSSA and 3-5 days for S. Pneumoniae
MRSA), and P. aeruginosa
Enteric Gram-negative MSSA community-acquired
pathogens, S. aureus (MSSA and pneumonia
MRSA), and P. aeruginosa a. non-bacteremic 7 14 days
b. Bacteremic longer up to 21
days

MRSA community-acquired
pneumonia
c. non-bacteremic 7 21 days
d. Bacteremic longer up to 28
days
DURATION OF ANTIBIOTIC USE
BASED ON ETIOLOGY

ETIOLOGIC AGENT DURATION OF THERAPY

(DAYS)

Mycoplasma and 10 14 days

Chlamydophilia
Legionella 14 21 : 10
(azalides)
What should be done for patient who are not
improving after 72hours of empiric antibiotic
therapy?

The lack of a response to seemingly

appropriate treatment in a patient with CAP
should lead to a complete reappraisal, rather
than simply to selection of alternative
antibiotics.
What should be done for patient who are not
improving after 72hours of empiric antibiotic
therapy?

The clinical history, physical examination

and the results of all available investigations
should be reviewed. The patient should be
reassessed for possible resistance to the
antibiotics being given or for the presence of
other pathogens. Treatment should then be
revised according to culture result.
What should be done for patient who are not
improving after 72hours of empiric antibiotic
therapy?

Follow-up chest radiograph is recommended

to investigate for other conditions such as
pneumothorax, cavitation, and extension to
previously uninvolved lobes, pleural effusion,
pulmonary edema and ARDS. For an
underlying mass, bronchiectasis, loculation,
pulmonary abscesses, a CT scan would
provide more information
What should be done for patient who are not
improving after 72hours of empiric antibiotic
therapy?

Obtaining additional specimens for

microbiologic testing should be considered.
 REASON FOR A LACK OF RESPONSE TO
TREATMENT OF CAP
Correct organism but inappropriate antibiotic choice or dose
Resistance of organism to selected antibiotic
Wrong Dose (e.g in a patient who is morbidly obese or has fluid overload)
Antibiotics not administered
Correct organism and correct antibiotic but infection is loculated (e.g.,
most commonly empyema)
Obstruction (e.g., lung cancer, foreign body)
Incorrect identification of causative organism
No identification of causative organism and empirical therapy directed
toward wrong organism
Non-infectious cause
Drug-induced fever
Presence of an unrecognized, concurrent infection
When can a hospitalized patient
with CAP be discharged?

In the absence of any unstable coexisting

illness or other life threatening complication,
the patient may be discharged once
clinically stable and oral therapy is initiated.
A repeat chest radiograph prior to hospital
discharge is not needed in a patient who is
clinically improving.
When can a hospitalized patient
with CAP be discharged?

A repeat chest radiograph is recommended

during a follow-up visit, approximately 4-6
weeks after hospital discharge to establish a
new radiographic baseline and to exclude
the possibility of malignancy associated with
CAP, particularly in older smokers.
 RECOMMENDED HOSPITAL
DISCHARGE CRITERIA
During the 24 hours before discharge, the
patient should have the following
characteristics (unless this represents the
baseline status):
1. Temperature of 36 37.5 C
2. Pulse <100/min
3. Respiratory rate between 16-24/minute
4. Systolic BP >90mmHg
5. Blood oxygent saturation >90%
6. Functioning gastrointestinal tract
 What other information should be
explained and discussed with patient?

Explain to patients with CAP that after

starting their symptoms are expected to
steadily improve, although the rate of
improvement will vary with the severity of
the pneumonia..
 What other information should be
explained and discussed with patient?

Most people can expect that by:

1 week: fever should be resolved
4 weeks: chest pain and sputum production
should have substantially reduced
6 weeks: cough and breathlessness should
have substantially reduced
3 months: most symptoms should have
resolved but fatigue may still be present
6 months: most people will feel back to normal.
 PHYSICAL EXAM on admission

Conscious, coherent, cooperative

In respiratory distress, febrile
BP = 120/80 mmHg
T = 38 C
HR = 120 bpm
RR = 32 cpm
O2 saturation = 98%
 PHYSICAL EXAM

CHEST & LUNGS:

equal chest expansion, increased tactile
fremitus and (+)rales heard over right lower
lung field) (-)intercostal retractions
 CVS:
PMI visible at 6th LICS AAL, 2.5cm in
diameter, bounding, (+) heaves, Heart rate:
114bmp, (+) systolic and diastolic murmur,
Grade IV, no extra heart sounds
 CLINICAL FORMULATION

Problem 1: Cough and Dyspnea

PRIMARY IMPRESSION:
Community Acquired Pneumonia
Moderate Risk
Hypertensive Cardiovascular Disease not
in Failure
 What antibiotics?

Piptaz
azith
 After 3 days?

Resolution of fever
Stable vital signs
Sputum culture: S. Pneumoniae sensitive to
piptaz, co-amox, cefu
 Streamline?

Co-amox
Thank you